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Nasogastric Intubation Medical NCO Course GI Tract • • • • Oral cavity Pharynx Esophagus Stomach • Small Intestine • Large Intestine • Accessory Structures Gastrointestinal System • Provides body with: – Water – Electrolytes – Other nutrients used by cells Gastrointestinal System • Function – Breaks down ingested food – Propels food through the GI tract – Absorbs nutrients across wall of lumen of GI tract – Absorbs water and salts – Eliminates waste Oral Cavity • Chemical Digestion – Salivary glands produce saliva – Contains digestive enzyme • Salivary amylase • Begins chemical breakdown of carbohydrates Oral Cavity • Mechanical Digestion – Mastication facilitates swallowing and processing of food – Food swallowed by voluntary and involuntary mechanisms – Pharynx elevates to receive food from mouth Oral Cavity • Mechanical digestion – Esophageal sphincter relaxes, opening esophagus – Food is pushed into esophagus – Epiglottis closes airway to prevent aspiration Medical NCO Course The Gastrointestinal System The Oral Cavity • Chemical digestion • Mechanical digestion Esophagus • Peristaltic waves Esophagus • Muscular canal (24 cm long) • Extends from pharynx to stomach • Begins below cricoid cartilage • Descends to sphincter of stomach Esophagus: •Muscular canal •About 24 cm long •Extends from pharynx to stomach Esophagus • Composition • Lined with mucous membrane • Peristaltic waves push food into stomach Stomach Structure • Layered muscular tube • Lined with mucous membranes • Contains gastric glands Stomach • Function – Storage and mixing chamber – Secretes HCl, intrinsic factor, gastrin, pepsinogen – Produces chyme – Moves chyme into duodenum Small Intestine • Begins at pyloric sphincter • Coils through abdominal cavity • Opens into large intestine Small Intestine • 10 ft divided into 3 segments – Duodenum – Jejunum – Ileum • Mixing and propulsion of chyme • Absorption of fluid and nutrients Small Intestine • Peristaltic contractions – Chyme moves through ileocecal valve • Chyme enters cecum • Cecum distends – Sphincter closes – Prevents contents from returning to ileum Large Intestine • • • • 1.2m (5ft) long 6.2cm (2.2in) in diameter Extends from ileum to anus Attached to abdominal cavity by mesocolon Large Intestine • Divided into four principal regions – Cecum – Colon – Rectum – Anal canal Large Intestine • • • • Absorbs water Absorbs salts Bacteria acts on undigested material Converts chyme into feces Liver Liver • Largest gland in body • Upper right quadrant • Vascular organ with 2 sources of blood supply – Hepatic artery – Portal vein Hepatic Artery Portal vein Liver Plays major role in: • Iron metabolism • Plasma-protein production • Detoxification Liver • Secretes bile – 600 – 1000 ml each day – Dilutes stomach acid (no digestive enzymes) – Emulsifies fats • Bile salts – Reabsorbed in ileum – Carried back to liver in blood – Also lost in feces Liver • Metabolism – Helps maintain blood glucose levels – Involved in fat and protein metabolism – Stores vitamins and minerals • Toxin Breakdown – Breaks down metabolism by-products – Can be toxic if accumulate in the body Liver • Blood Protein Production – – – – Albumin Fibrinogen Globulin Clotting factors Gallbladder • Pear shaped sac • 7-10 cm long (3-4”) • Located on posterior surface of liver • Hangs from anterior/inferior margin of liver Gallbladder • Secretes and stores bile produced by the liver Pancreas • Gland • 12-15 cm (5-6 in) long • 2.2 cm (1 in) thick • Posterior to the stomach • Connected to duodenum by 2 ducts Pancreas • Exocrine gland – Secretes pancreatic juice • Endocrine gland – Secretes hormones (insulin) into blood – Cells need insulin to process glucose Pancreas • Pancreatic juice – Most important digestive juice – Contains digestive enzymes, sodium bicarbonate and alkaline substances – Neutralizes HCl in juices entering small intestine Nasogastric Intubation NG Tube Indications • Aspirate stomach contents – Diagnostic or therapeutic • Assessment of GI bleeding • Determine gastric acid content NG Tube Indications • • • • • Treat paralytic ileus Treat intestinal obstruction Recurrent vomiting likely Trauma Overdose NG Tube Contraindications • Esophageal strictures • Alkali ingestion, caustic ingestions, esophageal burns • Comatose patients NG Tube Contraindications • Trauma patients with: – Cervical or intracranial bleeding – Increased intracranial pressure • Recent surgery of the following types: – Oropharyngeal – Nasal – Gastric Inserting NG Tube • Explain procedure • Position patient – – – – High Fowler if alert Drape Emesis basin Water and straw Inserting NG Tube • Unconscious patient – – – – – Left lateral position Head turned to downward side Gag and cough reflexes absent or suppressed NG tube easily misplaced (lung) Inability to swallow Inserting NG Tube • Check nares for patency • Select appropriate tube size • Determine length of insertion – Tip of nose, to ear, to xiphoid process – Mark tube S C10077/EC10077/E-3 1010-98 Inserting NG Tube • Lubricate tube – Lubricant must be water-soluble – May use topical anesthetic if available (ie, lidocaine) • Coil tube to shape it into curve • Have patient hold water and straw to mouth Inserting NG Tube • Insert tube – Along floor of nose – Straight back – Advance until resistance felt (nasopharynx) Inserting NG Tube Ask patient to swallow sips of water and flex neck slightly. As patient swallows, advance tube into and down esophagus. S C10077/EC10077/E-6 1010-98 Inserting NG Tube • When tube is in the esophagus: – Advance rapidly to the pre-marked distance Excessive choking, gagging, coughing, change in voice or condensation inside the tube indicates possibility of placement in trachea. The tube should be withdrawn. Confirm NG Tube Placement • X-ray – Most reliable if tube is radiopaque – Requires order from physician • Injecting air – – – – 60 cc catheter syringe Place stethoscope over LUQ of abdomen Inject air into lumen of tube, NOT blue pigtail Listen for “swoosh” sound Confirm NG Tube Placement • Aspirate stomach contents – 60 cc catheter tip syringe – Pull back to check for gastric aspirate – Possibility for fluid to be from lungs or pleural space Confirm NG Tube Placement • Test pH of gastric aspirate – 60 cc catheter-tip syringe and pH paper – pH < 4 = 95% chance that tip is in stomach – pH > 6 = may be in lung or pleural space; could be in stomach if patient takes antacids or some medications Confirm NG Tube Placement • Non-radiopaque methods – Possibility of error – Use more than one method – Passage into lungs frequent; especially in comatose or demented patients – Aspiration of gastric contents more reliable • Especially if tested with pH paper Securing the Tube • Secure to patient’s nose – Tape to nose and coil around tube – Avoid pressure to nares – Secure to patient’s clothing near shoulder area – Blue pigtail must be above level of patient’s stomach Complications Excessive coughing, motion, gagging may aggravate the following: • Neck injuries – Increased risk for C-spine injuries • Penetrating neck wounds – May increase hemorrhage • Tube misplacement – Pulmonary – Intracranial Removing NG Tube • Disconnect from drainage container and suction (if applicable) • Attach syringe-tip catheter to lumen of tube • Flush tube with 20cc of air – Empties contents from tube to prevent aspiration into lungs Removing NG Tube • Remove tape from patient’s nose • Unpin tube from gown • Have patient take deep breath and hold while tube is removed • Pull tube with quick and steady motion • Discard appropriately • Provide or instruct patient on oral and nasal care